Unit 2 Discussion 2 Treatment of Hyperlipidemia. 1000w. 4 references. Due 17

Unit 2 Discussion 2 Treatment of Hyperlipidemia. 1000w. 4 references. Due 17

Scenario

You are seeing a 62 year old white female for her annual visit.  Presented below are some pertinent subjective and objective data that you elicited during your comprehensive assessment session with the patient (note – this is not the entire subjective and objective data set for this office visit).

PMH :  HTN, Hyperlipidemia

Social History:  divorced, employed full time as a graduate nursing program professor, no smoking history, reports on a rare occasion she may have a 2 - 3 ounces of wine when dining out [less than 6 times a year]

Health Maintenance Activities: 1 ½ to 2 hours of exercise every morning [45 – 60 minutes of yoga, 45 – 60 minutes of step aerobics]; low glycemic Pescatarian; has not engaged with recommended colonoscopy, does not have screening mammograms, does not get a flu shot and has not had any other recommended adult immunizations

Review of Systems

Cardiovascular: reports hypertension diagnosed at 27 years of age, controlled on 5mg Lisinopril daily; reports elevated total cholesterol level for the last decade or so with no pharmacologic treatment; denies chest pains, palpitations, lower extremity edema

Physical Exam

Constitutional – Ht. 64 inches, Wt. 127 pounds [BMI 21.8], BP 112/60, P 68, T 97.9 temporal, R 16, SpO2 99%

Integument – pink, warm and dry to touch

Eyes – no arcus senilis

Cardiovascular – heart regular rate and rhythm, S1 and S2; no S3 or S4, murmur or gallop; no carotid bruits; radial pulses palpable and pedal pulses 2+; no lower extremity edema; capillary refill < 3 seconds bilateral

Lipid panel – Total cholesterol 302, HDL 117, Triglycerides 45

Please develop a discussion that responds to each of the following prompts.  Where appropriate your discussion needs to be supported by scholarly literature.  Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion.

Discussion Prompt

Utilize the information provided in the scenario to create your discussion post. 

1. Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan).

Structure your ‘P’ in the following format:  [NOTE:  if any of the 3 categories is not applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A]

2. Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional - any other therapies in lieu of pharmacologic intervention]

3. Educational: health information clients need in order to address their presenting problem(s); health information in support of any of the ‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit

4. Consultation/Collaboration: if appropriate - collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making.

Respond to the additional questions below.

5. What role does disease prevalence of hyperlipidemia play among groups such as the patient in the study?

6. Summarize a scholarly article that pertains to the case study and provide feedback.

Support the interventions outlined in your ‘P’ with scholarly resources.

Please be sure to validate your opinions and ideas with citations and references in APA format.

Example

Subjective (S):

62year old divorced white female with no chief complaint but visits the clinic for an annual

physical exam. The patient is employed full-time as a graduate nursing program professor. The

patient reports she does not smoke but drinks 2-3 ounces of wine when dining out on rare

occasions less than six times per year. Pt says the history of hypertension at age 27 and is

controlled with lisinopril 5mg daily PO and reported a high lipid level for the past ten years

without any pharmacological treatment. The patient also reports 1.5 hours to 2 hours of yoga and

aerobic exercise every morning and eating of low glycemic pescatarian diet. The patient denies

chest pain, palpitation, and edema of the lower extremities. The patient has not had a

colonoscopy or mammogram, nor does she get a flu shot or any recommended adult vaccines.

Objective (O):

 Constitutional – Ht. 64 inches, Wt. 127 pounds [BMI 21.8], BP 112/60, P 68, T 97.9

temporal, R 16, SpO2 99%

 Integument – pink, warm, and dry to the touch.

 Eyes – no arcus senilis.

 Cardiovascular – heart rate and rhythm, S1 and S2; no S3 or S4, murmur or gallop; no

carotid bruits; radial pulses palpable and pedal pulses 2+; no lower extremity edema;

capillary refill < 3 seconds bilateral.

 Lipid panel – Total cholesterol 302, HDL 117, Triglycerides 45

Assessment (O): uncontrolled hyperlipidemia

Plan/ Therapeutics:

Controlled hypertension (with medication).

 According to the patient history, it is evident that the nonpharmacological lifestyle

modification instituted by the patient is not lowering the cholesterol. It is, therefore,

necessary to start the patient on medication to lower cholesterol and protect against a

heart attack and stroke (Ramkumar et al., 2016).

 Based on the patient's Lipid panel – Total cholesterol 302, HDL 117, Triglycerides 45,

and high LDL of 176 (Normal less than 100) calculated using the Friedewald equation;

the patient will benefit from high-intensity Hydroxymethylglutaryl-CoA (HMG-CoA)

reductase inhibitors, or statins regimens such as atorvastatin (Lipitor) 40-80 mg or

rosuvastatin (Crestor) 20-40 mg to lower the LDL-C by approximately ≥ 50% (Arcangelo

et al., 2016).

 Additionally, the patient can use bile acid resin such as cholestyramine and colestipol that

binds with cholesterol-containing bile acid in the intestine and can be prescribed and used

safely with statins to increase cholesterol reduction by eliminating the stool (U.S.

National Library of Medicine, 2020). Also, nicotinic acid, which raises HDL and reduces

total cholesterol, LDL, and triglycerides, can be prescribed (Centers for Disease Control

and Prevention, 2021). The patient should continue antihypertensive medication to keep

blood pressure under control and reduce the risk of cardiovascular complications

associated with hypertension and hyperlipidemia.

Education

 Although this patient is highly educated and a professor of nursing who likely knows her

condition and treatment options, additional health education on the importance of

maintaining an average cholesterol level is essential. Although the patient has an average

BMI of 21.8 and eats a pescatarian diet that lowers cholesterol and engages in physical

activities, continuing these health-promoting lifestyles must be reinforced to reduce the

risk of complications. Also, the need for a routine colonoscopy and mammogram should

be emphasized as increased serum cholesterol level has been linked to a higher risk of

developing cancer such as colon, rectal and dietary cholesterol intake increases the risk of

breast cancer (Ding et al., 2019).

 The patient should also be educated to quit drinking wine, as alcohol can raise cholesterol

levels and the levels of triglycerides (Centers for Disease Control and Prevention, 2021).

The patient should also be educated on medication compliance, typical side effects of

prescribed medications, follow-up appointments to have cholesterol levels checked, and

the need to have recommended adult vaccines to prevent diseases.

Consultation/Collaboration

The patient may be referred to a gastroenterologist for a colonoscopy and GI evaluation and a

gynecologist for a mammogram, pap smear, and other wellness examinations. (Center for

Disease Control and Prevention, 2021). References

Arcangelo, V. P., Peterson, A. M., Wilber, V., & Reinhold, J. A. (2016). Pharmacotherapeutics or

advanced practice: A practical approach. 4th Ed. Philadelphia: Wolters Kluwer 10: 1496319966

Center for Disease Control and Prevention. (2021). Preventing and managing high cholesterol.

https://www.cdc.gov/cholesterol/prevention-management.htm

Ding, X., Zhang, W., Li, S., & Yang, H. (2019). The role of cholesterol metabolism in cancer.

American journal of cancer research, 9 (2), 219–227.

Ramkumar, S., Raghunath, A., & Raghunath, S. (2016). Statin therapy: Review of safety and

potential side effects. Acta Cardiologica Sinica, 32 (6), 631–639.

https://doi.org/10.6515/acs20160611a

U.S. National Library of Medicine. (2020). Bile acid sequestrants for cholesterol.

https://medlineplus.gov/ency/patientinstructions/000787.htm

Subjective: Mrs. X is a white 62-year-old female who has come into the office for her yearly exam. She states she

has a past medical history of hypertension and hyperlipidemia. Patient states that she exercises between 1.5 and 2

hours each morning doing yoga and step aerobics. She has a low glycemic pescatarian diet. The patient has not

received any preventative healthcare screenings like a colonoscopy or a mammogram. She also is not up to date onher adult immunizations or her yearly flu shot. Mrs. X is divorced and a nursing professor. She does not smoke and

only drinks occasionally.

o ROS Cardio: The patient states that they were diagnosed with hypertension at 27. She currently takes 5mg

of Lisinopril daily. She states that she has an elevated cholesterol level for a decade with no treatment.

Patient denies any chest pains, palpitations, or lower extremity edema.

Objective:

o Constitutional: Ht: 64 inches, Wt: 127 lbs (BMI: 21.8), BP: 112/60, P: 68, Temp: 97.9 temporal, R 16,

SpO2: 99%

o Integument: warm, pink, and dry to the touch

o Eyes: no arcus senilis

o Cardio: S1 and S2 have regular rate and rhythm; no S3 or S4 murmur or gallop. No carotid bruits, radial

pulses were palpable and pedal pulses 2+. No lower extremity edema. Capillary refill less than 3 seconds

bilaterally.

o Lipid panel: Total cholesterol 302, HDL 117, Triglycerides 45

Assessment: It is clear that the patient has extremely high cholesterol, hyperlipidemia, that needs to be controlled.

The patient is also at risk for a variety of other issues due to her refusal to participate in health screening.

Plan:

 Therapeutics: The highest priority for Mrs. X is getting her cholesterol under control. A total cholesterol

level of over 240 is considered high, so the fact that Mrs. X’s level is 302 is practically off the charts.

Similarly, her HDL should be less that 100, but that number is not as concerning. Finally, her HDL, or

triglycerides, is considered low, where a healthy level would be above 60 (Blesso & Fernandez, 2018). I

will be prescribing a statin, the first line of defense when it comes to high cholesterol. A statin will “lower

LDL cholesterol by slowing down the liver’s production of cholesterol. They also increase the liver’s

ability to remove LDL cholesterol that is already in the blood” (“Cholesterol-lowering…,” 2017). Lipitor,

one of the most common statins, is given to patients with extremely high levels at a dose of 40mg daily, to

be lowered as the condition improves.

 Educational: I will need to educate Mrs. X on the importance of preventative medicine. She has not

received the age recommended colonoscopy or mammogram screening, as well as not having gotten her flu

shot or any of her recommended adult immunizations. A colonoscopy, for example, is vital for a woman of

her age as it helps the doctor “identify possible problems very early on and can significantly reduce the risk

of colorectal cancer” (“The Importance…,” 2018). Similarly, a mammogram, can spot breast cancers before

any symptoms may occur. I need to help Mrs. X understand why these things should be an important part of

her own health maintenance.

 Consultation: I would recommend a consultation with a cardiologist to ensure that while her BP is not too

high that her past of hypertension and her current hyperlipidemia have not had any long-term effects on her

heart. I would also maybe consider a consultation with a counselor to find out why she will not get

recommended health screenings.

References

Blesso, C., & Fernandez, M. (2018). Dietary cholesterol, serum lipids, and heart disease. Nutrients, 10(4), 426-434.

doi:10.3390/nu10040426

Cholesterol-lowering medicine. (2017). Centers for Disease Control and Prevention. Retrieved from

https://www.cdc.gov/cholesterol/treating_cholesterol.htm

The importance of preventive health screenings. (2018). Rocky Mountain Health Plans. Retrieved from

https://www.rmhp.org/blog/2018/may/the-importance-of-preventive-health-screenings-rmhp